Intraoperative Ultrasound in Brain and Spine Surgery: Current Applications, Translational Value and Future Perspectives

Intraoperative ultrasound (IOUS) has developed from a rudimentary adjunct into a versatile modality that now plays a crucial role in neurosurgery. Offering real-time, radiation-free and repeatable imaging at the surgical site, it provides distinct advantages over intraoperative magnetic resonance (MRI) and computed tomography (CT) in terms of accessibility, workflow integration and cost. The clinical spectrum of IOUS is broad: in cranial surgery it enhances the extent of resection of gliomas and metastases, supports dissection in meningiomas and enables localization of MRI-negative pituitary adenomas; in spinal surgery, it guides resection of intradural and intramedullary tumors, assists in myelotomy planning and confirms decompression in degenerative conditions such as cervical myelopathy and ossification of the posterior longitudinal ligament. IOUS also offers unique insights into cerebrospinal fluid disorders, including arachnoid webs, cysts, syringomyelia and Chiari malformation, where it visualizes cord compression and CSF flow restoration. In trauma and oncological emergencies, it provides immediate confirmation of decompression, directly influencing surgical decisions. Recent innovations, including contrast-enhanced ultrasound, elastography, three-dimensional navigated systems and experimental integration with artificial intelligence and robotics, are extending its functional scope. Despite heterogeneity of evidence and operator dependence, IOUS is steadily transitioning from an adjunctive tool to a cornerstone of multimodal intraoperative imaging, bridging precision, accessibility and innovation in contemporary neurosurgical practice.